ASUHAN KEPERAWATAN PADA Ny..................

DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........

I. PENGKAJIAN
A. IDENTITAS PASIEN PENANGGUNG/ SUAMI
Nama : ............ Nama : ...................
Umur : ............ Umur : ……………
Pendidikan : ............ Pendidikan : ……………
Pekerjaan : ............ Pekerjaan : …................
Status perkawinan : ............ Alamat : ...................
Agama : ............
Suku : ............
Alamat : ............
No. CM : ............
Tangal MRS : ............
Tanggal Pengkajian : ............
Sumber informasi : ............

B. ALASAN DIRAWAT
1. Alasan MRS
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 2. Keluhan saat dikaji
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C. RIWAYAT MASUK RUMAH SAKIT

Keluhan Utama (saat MRS dan sekarang)
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Riwayat persalinan sekarang (kala I-IV)

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Keadaan bayi sekarang

BB .............................. Lingkar kepala......................Lingkar dada.......................Lingkar
perut...............................dll.......................................
 D. RIWAYAT OBSTERTRI DAN GINOKOLOGI
a. Riwayat Menstruasi :
 Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : .................... Lamanya : .....................................
 Keluhan : ....................
b. Riwayat Pernikahan :
 Menikah : ....................kali Lama : ................. tahun.

c. Riwayat kelahiran, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur Jenis
No Th Penyulit Jenis Penolong Penyulit Laserasi Infeksi Pedarahan BB Pj
kehamilan kelamin

d. Riwayat Keluarga Berencana :

 Akseptor KB : jenis .............. Lama : ..................
 Masalah : .......................
 Rencana KB : ......................

E. POLA KEBUTUHAN SEHARI-HARI

1. Bernafas
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2. Nutrisi (makan/minum)
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3. Eliminasi
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4. Gerak Badan
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5. Istrirahat tidur
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6. Berpakaian
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7. Rasa Nyaman
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8. Kebersihan Diri
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9. Rasa Aman
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10. Pola Komunikasi/Hubungan Dengan Orang Lain
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11. Ibadah
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12. Produktivitas
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13. Rekreasi
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 14. Kebutuhan belajar
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E. PEMERIKSAAN FISIK
Keadaan umum
- GCS : ......................................
- Tingkat kesadaran : ......................................
- Tanda-tanda fital : TD ............. N .............. RR .............. T ...............
- BB : ................... TB : ............... LILA : ........

Head toe toe :

 Kepala
Wajah : ..................................................................................................
Pucat ( )
Cloasma ( )
Sklera : ..................................................................................................
Konjungtiva : : ..................................................................................................
Pembesaran limphe node : ............................................................................................
Pembesaran kelenjar tiroid :............................................................................................
Telinga : .................................................................................................

 Dada
Payudara
Areola :…………….. Putting : (menonjol / tidak )
Tanda dimpling / retraksi :………………….
Pengeluaran ASI : ………………..
Jantung : ………. Paru: …………..
 Abdomen :
o Linea : ............................................. Striae : ....................
Luka SC...........................................................
o Bising usus : .............................................
o TFU : .............................................
o Kontraksi : .............................................
o Diastasi rectus abdominis : ......................................
 Genetalia
o Kebersihan : ......................................
o Lokhea : ...................................... Krakteristik : ..........................
 Perineum dan anus
o Perineum : REEDA (red, eodem, ekimosis, discharge, lost of
approximate)
o Hemoroid : ......................................
 Ekstremitas :
Atas : ......................................
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Bawah
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Tanda homan : ......................................
Pemeriksaan Reflek : ......................................
F. DATA PENUNJANG
 Pemeriksaan Laboratorium
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  Pemeriksaan radiologik
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F. DIAGNOSA MEDIS
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G. PENGOBATAN
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II. ANALISA DATA
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ETIOLOGI MASALAH
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Diagnosa keperawatan berdasarkan prioritas :
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 III. RENCANA KEPERAWATAN
Rencana Keperawatan
No Tgl / jam Diagnosa
Tujuan Intervensi Rasional
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IV. IMPLEMENTASI
No.
Tgl/Jam Implementasi Evaluasi Proses Paraf/Nama
Dx
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IV. EVALUASI
Tgl/Jam No Dx Evaluasi Hasil
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 Denpasar, …………………….2017
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

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NIP: NIM:

Clinical Teacher/CT

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NIP